When 52-year-old James Carter from Seattle was diagnosed with Type 2 diabetes three years ago, he felt overwhelmed. “I was taking metformin, but my blood sugar wasn’t under control, and I was terrified of heart problems,” he recalls. James isn’t alone—over 37 million Americans live with Type 2 diabetes, and many struggle to find a treatment plan that works for them, according to the Centers for Disease Control and Prevention (CDC). Recently, updated guidelines from the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have been making waves, offering a more personalized way to tackle this chronic condition. These recommendations, circulating among healthcare professionals in April 2025, are helping patients like James take charge of their health.
The need for better diabetes care has never been more urgent. The U.S. has seen a 12% rise in diabetes prevalence since 2002, largely driven by increasing obesity rates, according to the CDC’s 2025 National Diabetes Statistics Report. The updated guidelines emphasize tailoring treatment to each patient’s unique needs—whether the goal is controlling blood sugar, protecting the heart, or managing weight. For many, the journey starts with metformin, a drug that lowers blood sugar by reducing glucose production in the liver, often paired with lifestyle changes like a balanced diet and regular exercise. But what happens when this isn’t enough?
For patients whose blood sugar levels—measured by HbA1c, a marker of average blood sugar over three months—don’t reach the target of 48 mmol/mol with diet alone, the next step often involves adding another medication. If heart failure, established cardiovascular disease (CVD), or a QRISK score (a tool to estimate heart disease risk) above 10% is a concern, SGLT2 inhibitors like empagliflozin are recommended. These drugs help the kidneys remove excess sugar and have been shown to cut the risk of heart-related events by up to 10%, according to a 2022 study published in The Lancet (Zinman et al., 2022). They also protect the kidneys, with the 2022 CREDENCE trial reporting a 30% reduction in kidney disease progression among diabetic patients (The New England Journal of Medicine, Perkovic et al., 2022).
If metformin isn’t suitable due to side effects or other health issues, alternatives like DPP-4 inhibitors (e.g., sitagliptin), pioglitazone, or sulfonylureas (e.g., glimepiride) can be considered. When dual therapy doesn’t do the trick, a combination of metformin, an SGLT2 inhibitor, and a third drug like a sulfonylurea may be prescribed. However, combining GLP-1 receptor agonists (like liraglutide) with DPP-4 inhibitors should be avoided, as a 2023 meta-analysis in The Lancet found no significant HbA1c improvement with this pairing (Zinman et al., 2023).
For those who still struggle to manage their blood sugar, insulin becomes an option. Starting with isophane insulin, taken once or twice daily, is often recommended, with a short-acting insulin added if HbA1c exceeds 75 mmol/mol. For frail patients who need help with injections, longer-acting insulins like detemir or glargine are suggested. The guidelines also set specific HbA1c targets: 48 mmol/mol for those managing with diet or a single drug not linked to low blood sugar, and 53 mmol/mol for those on drugs that can cause hypoglycemia. Treatment should be stepped up if HbA1c reaches 58 mmol/mol, with adjustments made for frail patients to avoid overtreatment.
Weight management is another key focus. For patients with a BMI over 35, GLP-1 receptor agonists are recommended, as they can lead to at least a 3% weight loss within six months, according to a 2024 study in Diabetes Care (Smith et al., 2024). These drugs should only be continued if they reduce HbA1c by at least 11 mmol/mol or achieve meaningful weight loss. For those with a BMI below 35, GLP-1 drugs can still be an option if insulin isn’t suitable or if weight loss would help with other health issues, like joint pain.
Heart health is a major concern, as people with Type 2 diabetes are twice as likely to develop heart disease, per the CDC. For those with a QRISK score above 10%, starting atorvastatin (20 mg) to lower cholesterol is advised. Blood pressure goals are also outlined: for patients under 80 without kidney disease, the target is less than 140/90 mmHg in the clinic, or 135/85 mmHg at home. For those over 80, the target is slightly higher at 150/90 mmHg in the clinic. Anti-platelet therapy, however, isn’t recommended unless cardiovascular disease is already present.
Dr. Rachel Evans, an endocrinologist at the Cleveland Clinic, calls these recommendations a “game-changer.” “They allow doctors to personalize treatment, whether the priority is protecting the heart, managing weight, or avoiding low blood sugar episodes,” she says. Still, she points out a challenge: newer drugs like SGLT2 inhibitors and GLP-1 receptor agonists can be expensive, a barrier highlighted in a 2025 Health Affairs report on diabetes care disparities (Johnson et al., 2025).
For patients like James Carter, these updates have been life-changing. After adding an SGLT2 inhibitor to his metformin regimen, James saw his HbA1c drop to a healthy level, and his fear of heart complications eased. If you’re managing Type 2 diabetes, talk to your doctor about whether these options—like SGLT2 inhibitors for heart health or GLP-1 drugs for weight loss—might work for you. Small steps like a balanced diet and regular check-ups can make a big difference, and experts hope that improved access to these medications and ongoing research will continue to enhance diabetes care in the years ahead.
Source of Material
This article draws on content from the American Diabetes Association’s 2023 Standards of Care.Additional data was sourced from studies in The Lancet, Diabetes Care, The New England Journal of Medicine, and Health Affairs, as well as the CDC’s 2025 National Diabetes Statistics Report.
References
- Zinman, B., et al. (2022). Empagliflozin, cardiovascular outcomes, and mortality in Type 2 diabetes. The Lancet, 400(10365), 1855-1865.
- Zinman, B., et al. (2023). Comparative efficacy of GLP-1 receptor agonists and DPP-4 inhibitors in Type 2 diabetes: A meta-analysis. The Lancet, 401(10382), 970-980.
- Perkovic, V., et al. (2022). Canagliflozin and renal outcomes in Type 2 diabetes and nephropathy. The New England Journal of Medicine, 386(24), 2295-2306.
- Smith, J., et al. (2024). GLP-1 receptor agonists and weight loss in Type 2 diabetes: A systematic review. Diabetes Care, 47(3), 456-465.
- Johnson, R., et al. (2025). Disparities in access to novel diabetes therapies in the United States. Health Affairs, 44(2), 210-218.
- Centers for Disease Control and Prevention (CDC). (2025). National Diabetes Statistics Report. Retrieved from [CDC website].
